Is the stethoscope dead?

The stethoscope is having a crossroads moment. Perhaps more than at any time in its two-century history, this ubiquitous tool of the medical profession is at the centre of debate over how medicine should be practised.

In recent years, the sounds it transmits from the heart, lungs, blood vessels and bowels have been digitised, amplified, filtered and recorded.

Last year, the US Food and Drug Administration approved a stethoscope that can faithfully reproduce those sounds on a mobile phone app or send them directly to an electronic medical record.

Algorithms already exist that can analyse the clues picked up by a stethoscope and offer a possible diagnosis.

But whether all this represents the rebirth of diagnostic possibility or the death rattle of an obsolete device is a subject of spirited discussion in cardiology.

The widespread use of echocardiograms and the development of pocket-sized ultrasound devices are raising questions about why doctors and others continue to sling earphones and rubber tubing around their necks.

“The stethoscope is dead,” said Jagat Narula, associate dean for global health at the Icahn School of Medicine at Mount Sinai Hospital in New York. “The time for the stethoscope is gone.”

Not so, counters W. Reid Thompson, an associate professor of paediatrics at Johns Hopkins University School of Medicine in Baltimore. “We are not at the place, and probably won’t be for a very long time,” where listening to the body’s sounds is replaced by imaging. “It is valuable,” he said.

One thing on which both sides agree, however, is that doctors aren’t very good at using stethoscopes — and haven’t been for a long while. In 1997, researchers examined how well 453 physicians in training and 88 medical students interpreted the information obtained via stethoscope.

According to their study, “both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events”.

‘Doctors are conservative’
Nineteen years later, another team tried to determine when doctors stopped improving at “auscultation” — listening to the body to detect disease. The answer: after the third year of medical school.

Worse, the researchers wrote in the Archives of Internal Medicine, that skill “may decline after years in practice, which has important implications for medical decision-making, patient safety, cost-effective care and continuing medical education”.

In 2016, the device remains one of the last instruments that health care providers use to infer the nature of a problem, rather than viewing it directly.

Doctors “are the most conservative people on earth”, said Sanjiv Kaul, head of the division of cardiovascular medicine at the Oregon Health and Science University. “Once they have learnt something, they don’t want to learn something else.” The stethoscope is also an icon, of course. Yet it carries more than symbolic value. It narrows the physical distance between doctor and patient. It compels human touch.

Medicine’s familiar list of woes is at least partly to blame for auscultation’s decline. Doctors, especially the overworked medical residents who staff hospitals, have much less time to spend with patients.

That means less time for physical examinations, including listening with stethoscopes. The demands of electronic medical records have further eaten into time with patients, many doctors complain.

“It’s all chart rounds and computer readout rounds. It’s horrible. I cringe,” said John M Criley, professor emeritus of medicine and radiological sciences at the David Geffen School of Medicine at UCLA.

For decades now, it has been easier to send a heart patient for an echocardiogram, and that increasingly sophisticated imaging test has proven more accurate than scope-to-chest interpretation of the human heart.

Some doctors point out glumly that providers and hospitals can charge separately for echocardiograms. A chest exam with a stethoscope nets nothing extra.